Wow, do we really not have a topic on this? I can only assume that I either suck at searching or it has taken place entirely under other topics such as the Barack Obama topic?

Anyway, the PPACA has been in effect in the United States, in some stages, for a while now, and people are starting to feel changes due to it. There are still other stages which are scheduled to go into effect, and it's also front-and-center in politics as Mitt Romney faces off against President Barack Obama. The Supreme Court has ruled that the PPACA clause that requires everyone to maintain an insurance plan (it actually has options which allow people to file for exclusion for various reasons) is constitutional and effectively labeled it as a tax, which is now the latest twist the Republicans are using to convince everyone it is the end of the world as we know it.

I was curious what experiences anyone may have actually had with changes caused by this bill. But if this really is our first dedicated topic on it, discussion about the bill is certainly welcome as well.

tens of millions of people are going to be moved into the 'normal' healthcare system, without any commensurate increase in number of doctors. so, the quality of healthcare is going to go down, or its cost is going to increase, or both. a lot of these new customers are going to have to pay for it where they didn't want to before, and didn't need to. young people are not a burden on the healthcare system, but now they're going to be required to subsidize it. this isn't going to change healthcare costs - instead of coming from hospital writeoffs, or individual bankruptcies, the money will come from young, healthy people. you can say that this is a fair shifting of the burden, but it's also a drag on the people who should be the most liquid. insurance companies are going to have to artificially distort how they distribute premiums in order to meet requirements in the law. the government is going to have to spend more to collect and process the fees collected from people who don't comply with the law, and to enforce the vast complexity of it.

the end result of all this is that the system isn't going to work better, it's going to cost more, and the true value of healthcare - which is already obscured by all the layers of insurance and healthcare corporation bureaucracy that we already have - is just going to be more obscured. i think that this law is just going to allow the situation to get worse than it would have before, before there is finally a real crisis that forces real reform, which probably will include removal of all interstate restrictions on insurance companies, and parallel institution of a reformed national healthcare system for the poor.

that's what i think, anyways. it's a bad law, whether it's constitutional or not. it's one reason (of many) that i am not voting for obama this fall. i think he's likely to push more of this kind of thing.

I agree it's a bad law (logistically), but unfortunately for this position, it has been ruled constitutional as a tax. Neither you nor I have the prerogative or the right to claim otherwise - only the SCotUS has the power to make that determination. I think that point should be cleared up here.

Also, I will note that conservatives and libertarians have been rather reticent to come forward with their alternatives to Obamacare. I know that there are alternatives which were widely discussed and aired on the side of those of us pushing for HCR (including universal healthcare and the 'public option' which were among the first proposals to get the legislative axe). The most I have heard coming from the fusionist side, other than the stale and predictable calls for trimming 'waste' from Medicare and Medicaid, is precisely the proposal to allow insurance companies to expand their bases across state lines (though from this:

agga wrote:i think that this law is just going to allow the situation to get worse than it would have before, before there is finally a real crisis that forces real reform, which probably will include removal of all interstate restrictions on insurance companies, and parallel institution of a reformed national healthcare system for the poor.

I gather you probably wouldn't be in favour of that, either). I also recall the libertarians calling for privatising the system by creating private-use medical savings accounts in place of the federal insurance mandate, but given the nature of such accounts, such proposals would require much more invasive and bloated regulation (involving more federal departments, which would mean greater levels of institutional overlap and evasion of responsibility should something go wrong, etc.) than Obamacare already does. Hardly seems like an improvement.

agga wrote:tens of millions of people are going to be moved into the 'normal' healthcare system, without any commensurate increase in number of doctors. so, the quality of healthcare is going to go down, or its cost is going to increase, or both. a lot of these new customers are going to have to pay for it where they didn't want to before, and didn't need to. young people are not a burden on the healthcare system, but now they're going to be required to subsidize it.

This argument is a complete red herring, but an understandable one given the way Obamacare is discussed. What we are discussing here is not the provision of primary care, but rather the mandate requiring people to pay for health insurance. Healthcare provision has not been significantly impacted by PPACA - that's something that is conveniently forgotten by both sides in the attempt to score political points - but access to healthcare becomes more problematic.

If there is an objectionable side to this law, it is not that it will drive up healthcare costs or cause healthcare quality to decline (it will do neither; the material point is that neither will they cause costs to decrease or quality to improve), but rather that it will entrench the insurance industry, which (as a form of legalised gambling) has a vested interest in stacking the odds in the favour of the house. The insurance companies, given that they are still motivated to maximise profit, will still find means within the new system of rationing care (or rather, their own liability for it), even if those means are not equitable. That should be the primary concern here. As you say:

agga wrote:insurance companies are going to have to artificially distort how they distribute premiums in order to meet requirements in the law.

This is true. But it is worth keeping the issues separate, for obvious reasons. Healthcare and access to healthcare are two different issues.

There are several reasons that barriers to access are so high for healthcare in the United States. One of them is precisely that the insurance companies are in the way. Revoking regulations which limit competition amongst insurance companies and using antitrust legislation to break up large insurance companies and ensure that local, cooperative alternatives could compete with them could be one way of driving down costs. Another way would be to alter the tax structure to subsidise charitable provision of healthcare (i.e. by religious institutions), which would make healthcare more available to people who really need it. Thirdly, on the supply side, we could pass regulations making it easier to re-establish a medallion or a guild system for doctors through medical schools, to drive down the costs of getting an MD (and ensuring that one has a practice once one enters the field). There are other good proposals out there which provide ways of getting around the insurance oligopoly, which remains the central problem when talking about the systematic high costs of healthcare in the United States.

The problem with Obamacare is precisely the problem with conservative gripes against Obamacare - it is unimaginative and it is obstructive to the end goal of making healthcare more accessible to the absolute neediest.

Some more blood, Chekov. The needle won't hurt, Chekov. Take off your shirt, Chekov. Roll over, Chekov. Breathe deeply, Chekov. Blood sample, Chekov! Marrow sample, Chekov! Skin sample, Chekov! If I live long enough... I'm going to run out of samples.

I agree it's a bad law (logistically), but unfortunately for this position, it has been ruled constitutional as a tax. Neither you nor I have the prerogative or the right to claim otherwise - only the SCotUS has the power to make that determination. I think that point should be cleared up here.

yes. i'm just emphasizing the general point that lawfulness isn't righteousness.

WeiWenDi wrote:I know that there are alternatives which were widely discussed and aired on the side of those of us pushing for HCR (including universal healthcare and the 'public option' which were among the first proposals to get the legislative axe).

like so many other things our government (like most others) does, this is just a papering-over of deeper problems. it's an addition of law and regulation, of complication. it's obfuscating the way that the healthcare system works. the fact that more sensible alternatives - which would be destructive in the short term to the hospital and insurance industries - are excluded from real consideration because of short-term interests of corporations, well.. it's not an excuse for passing a bad law that perfectly satisfies these interests.

WeiWenDi wrote:I gather you probably wouldn't be in favour of that, either). I also recall the libertarians calling for privatising the system by creating private-use medical savings accounts in place of the federal insurance mandate.... Hardly seems like an improvement.

i am still not a libertarian, though lately i keep finding myself siding with them on practical terms. i do think there should be a national healthcare system for the poor. premiums should be subsidized through wealth redistribution, from the top to the bottom. i am not against this.

WeiWenDi wrote:What we are discussing here is not the provision of primary care, but rather the mandate requiring people to pay for health insurance. Healthcare provision has not been significantly impacted by PPACA - that's something that is conveniently forgotten by both sides in the attempt to score political points - but access to healthcare becomes more problematic.

this isn't quite what i meant, but it's close enough. you're wrong here. once people have health insurance who wouldn't have bought it before, they will indeed use it. they will go for checkups, they will go for medicine when they have cold or allergies or other problems that they otherwise would have successfully stuck out. they will be adding a great deal of demand to the system, and new supply is not going to appear. again, prices will go up or quality will decrease, or both. neither is desirable, especially since prices are already too high.

WeiWenDi wrote:the insurance industry, which (as a form of legalised gambling) has a vested interest in stacking the odds in the favour of the house. The insurance companies, given that they are still motivated to maximise profit, will still find means within the new system of rationing care (or rather, their own liability for it), even if those means are not equitable.

insurance can be done well or not. if it's done right, what you pay is proportional to the likelihood that you will need compensation. for most people, it's a way to save money in the long run. i've been paying for my own car insurance for more than 10 years now; i've probably paid something like 5 or 6 thousand dollars for it in that time. i consider it a good investment, considering what might have happened if i had been in an accident and been found at fault - lucky for me, it never happened. if that's gambling, then so would have been never buying insurance at all, and betting on good luck.

WeiWenDi wrote:Revoking regulations which limit competition amongst insurance companies and using antitrust legislation to break up large insurance companies and ensure that local, cooperative alternatives could compete with them could be one way of driving down costs. Another way would be to alter the tax structure to subsidise charitable provision of healthcare (i.e. by religious institutions), which would make healthcare more available to people who really need it. Thirdly, on the supply side, we could pass regulations making it easier to re-establish a medallion or a guild system for doctors through medical schools, to drive down the costs of getting an MD (and ensuring that one has a practice once one enters the field).

yes, yes, and yes. none of these are in the law that was passed.

and, yes, there is a single good thing about the law: more people will have insurance than before, and they will therefore be protected from catastrophic financial situations (bad luck). the way this was accomplished was, i think, a total mess which is a negative in every other sense.

agga wrote:the fact that more sensible alternatives - which would be destructive in the short term to the hospital and insurance industries - are excluded from real consideration because of short-term interests of corporations, well.. it's not an excuse for passing a bad law that perfectly satisfies these interests.

I agree with this completely. I think critics of Obamacare from left and right very much see eye-to-eye on this one, actually.

agga wrote:i do think there should be a national healthcare system for the poor. premiums should be subsidized through wealth redistribution, from the top to the bottom. i am not against this.

Ah, I see. This was not quite clear from your previous post - it sounded on first read like you considered a national healthcare system to be an undesirable end result of Obamacare. Sorry if I misinterpreted you on that one.

agga wrote:this isn't quite what i meant, but it's close enough. you're wrong here. once people have health insurance who wouldn't have bought it before, they will indeed use it.

Erm... no. Let's think about the incentive structures for a moment.

I am a perfectly healthy individual who was first not covered by insurance because of my SCHIP status being unclear, then who was mandated by employer to purchase insurance from Aetna, and now once again falls under his parents' insurance under BC/BS thanks to changes in the SCHIP implementation under the PPACA. I personally have not used any more actual coverage while insured than when I was uninsured. People get care when they need it - as I recall, this was your argument as to why PPACA represented an unfair burden on young people who would, under this scheme, be paying more than their fair share. Usage of insurance (on the consumer side) becomes an issue only in extremo.

Actually, in my behavioural economics course, healthcare provision was used as one of the textbook examples where adverse incentives did not apply.

agga wrote:insurance can be done well or not. if it's done right, what you pay is proportional to the likelihood that you will need compensation. for most people, it's a way to save money in the long run.

Right. Because 99% of the time, they don't use it, and the 1% of the time they need it, it helps to cut costs drastically. For car insurance, this is all well and good - though even there, the odds are stacked in the house's favour, and they do this by charging higher premiums to higher-risk customers. Young men, for example, and drivers under 25. (Actually, that's one of the reasons why I still don't have a car.)

But in the case of health insurance, the incentives on the supply side are so fucked that it's impossible to do it correctly. The people who most need compensation are quite often the people at the highest risk - and they're very often the same people who can't afford to pay into the system and end up fronting the bill on their own dime anyway. The incentive structure of the health insurance system is such that it needs to be done away with (or at the very least, the regulatory conditions which allow for an oligopoly).

agga wrote:yes, yes, and yes. none of these are in the law that was passed.

Which is my main gripe with the law. It's essentially a direct taxpayer subsidy for the insurance companies. Not imaginative or creative at all, and it doesn't solve the root problems which led to the need for the law in the first place.

Some more blood, Chekov. The needle won't hurt, Chekov. Take off your shirt, Chekov. Roll over, Chekov. Breathe deeply, Chekov. Blood sample, Chekov! Marrow sample, Chekov! Skin sample, Chekov! If I live long enough... I'm going to run out of samples.

WeiWenDi wrote:I personally have not used any more actual coverage while insured than when I was uninsured. People get care when they need it - as I recall, this was your argument as to why PPACA represented an unfair burden on young people who would, under this scheme, be paying more than their fair share. Usage of insurance (on the consumer side) becomes an issue only in extremo.

as a counter anecdote, i have certainly used more than i would have otherwise (if i didn't have insurance). i've had several relatively minor injuries (thank you taekwondo) over the past few years that i went and had checked out just in case. each time, turns out there was nothing to do but wait and heal. colds.. headaches... various things.. if i didn't have the insurance, i would, like i said, have stuck it out each time.

this is the only way the effect can go. insuring more people can't subtract from demand. you can add zero or something, but you can't take away.

i only list this effect as one of several reasons why the content of the law is not a good thing. i'm not claiming it's a primary effect, only that it's a necessary one. my main point is that this sort of law just serves to distort and obscure the value of what is being bought and sold, which usually means that money is going the wrong way. i am attracted to efficiency, clarity, and practicality.

WeiWenDi wrote:But in the case of health insurance, the incentives on the supply side are so fucked that it's impossible to do it correctly. The people who most need compensation are quite often the people at the highest risk - and they're very often the same people who can't afford to pay into the system and end up fronting the bill on their own dime anyway. The incentive structure of the health insurance system is such that it needs to be done away with (or at the very least, the regulatory conditions which allow for an oligopoly).

so there should be some option for the poor, i.e. people who can't afford to pay for the rates their conditions warrant. and i think this should be paid for through straightforward wealth redistribution, through progressive taxation. meanwhile, insurance markets, profit-driven as they are, should be freed up and then left largely alone.

i do like the idea, found to some degree in the PPAC, that fine-print allowing insurers to drop patients whose condition has changed should be prohibited, or at least made loud-and-clear when a policy is bought. insurance contracts should be fairer and clearer, which with more competition might lead to better quality. but having the congress, in effect, set narrow limits on insurance rates basically means they are setting prices. this is not the answer to the problem. (fyi, i also don't think they should be setting labor prices either, i.e. i think the minimum wage is bad. let the state subsidize low-wage workers through progressive taxation. yeah, that's my answer for everything, basically... free markets and progressive taxes!)

I'm not sure, yet, how I feel about the law as a whole—whether I believe it is a good law or a bad law—but there's definitely some comments here which deserve responses.

agga wrote:tens of millions of people are going to be moved into the 'normal' healthcare system, without any commensurate increase in number of doctors. so, the quality of healthcare is going to go down, or its cost is going to increase, or both.

Are they really going to do that? I wonder how many of these people have already been going when bad things are happening with their health and allowing the tax payer to flip the bill. Now, people in that circumstance generally only go when something is really wrong with them, so if they have healthcare they could certainly wind up going more, but is it such a bad thing that they will have healthcare? Healthcare which they are actually paying for in many cases?

As for doctors, if demand for healthcare goes up, demand for doctors go up. I think the economics behind this are a little too hard to predict at this stage because I couldn't say with certainty how all of it is going to play out, but I don't think that will be a problem.

agga wrote: a lot of these new customers are going to have to pay for it where they didn't want to before, and didn't need to. young people are not a burden on the healthcare system, but now they're going to be required to subsidize it. this isn't going to change healthcare costs - instead of coming from hospital writeoffs, or individual bankruptcies, the money will come from young, healthy people. you can say that this is a fair shifting of the burden, but it's also a drag on the people who should be the most liquid.

Through various means many of these write-offs also find their way to the taxpayer, which is worth consideration. Also, I would be completely opposed to the individual mandate if people who chose not to pay into the healthcare system were also willing to accept a lower standard of care when they needed major medical attention, but as it stands, when someone's life is in danger, the hospital will use every option open to it to save their lives regardless of healthcare. I still don't feel confident of what is or is not the right solution here, but I think it is reasonable to pay something if you expect the hospitals to rescue you.

Now, that's under our current system. There are other healthcare systems where the government provides for everyone, and if that were the case in the United States I would feel differently, but we don't have one of those systems.

agga wrote:insurance companies are going to have to artificially distort how they distribute premiums in order to meet requirements in the law. the government is going to have to spend more to collect and process the fees collected from people who don't comply with the law, and to enforce the vast complexity of it.

I'm not sure we could say anything in confidence here. For example, even if the government has some overhead processing these payments, they are receiving those payments, which offsets costs. As for the private insurance companies, there's a lot of room open for them to approach it from different angles. What happened to a friend of mine suggests that those avenues may not necessarily be the most ethical or balanced ones, but it doesn't have to be broken for everyone.

agga wrote:the end result of all this is that the system isn't going to work better, it's going to cost more, and the true value of healthcare - which is already obscured by all the layers of insurance and healthcare corporation bureaucracy that we already have - is just going to be more obscured. i think that this law is just going to allow the situation to get worse than it would have before, before there is finally a real crisis that forces real reform, which probably will include removal of all interstate restrictions on insurance companies, and parallel institution of a reformed national healthcare system for the poor.

That's definitely a possibility. But I'm not sure it has to be the outcome.

agga wrote:that's what i think, anyways. it's a bad law, whether it's constitutional or not. it's one reason (of many) that i am not voting for obama this fall. i think he's likely to push more of this kind of thing.

And now on to other aspects of the law. PPACA addresses certain insurance company practices such as dropping someone once they cease to become profitable (I'm not sure people really think about how horrific that practice really is). It also extends healthcare to many people who can't even get healthcare under the current system.

I can actually use myself as an example here. I have something called a 'regular irregular heartbeat'—my heart skips a beat (irregular) but it is benign and not dangerous to my health (regular). At least that's the best explanation I can come up with for the odd name. Anyway, under pre-PPACA healthcare, I have two choices: 1) I can overlook the 'heart conditions' checkbox in my application and make no mention of my harmless heart condition; or 2) I can check that box, indicate that it is harmless, and try to follow through in getting coverage. But here's what happens. If I check it, I am declined coverage. Period. I can't even get an insurance company to have a doctor review my condition, or review paperwork supporting that it is harmless. If there's something irregular with your heart they don't want anything to do with you. If I don't click the box, I've set myself up for the perfect scenario where coverage is dropped when I need it most. They'll provide me coverage and take care of little things, but maybe down the road I'm hit by a car and I'm in the hospital with hundreds of thousands of dollars in bills. Suddenly I'm big enough an issue that my circumstance warrants human eyes. They review my medical history, see that I didn't mention my harmless heart condition, and drop my coverage because I 'lied on my application' (and that's a very easy claim to make).

If that's not a representation of some of the things that are so completely messed up with our healthcare system I'm not sure what is, and yet PPACA addresses many of these problems, and few people really talk about this. It also helps with coverage for children, coverage for young adults at home as they transition into independence, and more. And unlike Republican claims, it isn't projected to be the deficit-inflating drain that some believe it will be.

Now that doesn't mean I'm in full support of it. I have a good friend named David who—also a self-employed professional—saw his monthly rates jump from around $300 to $600, for no logical reason, and that's just insane. That's private insurance cheating him right there—most people with regular jobs aren't subject to that sort of thing—and I'm not sure how well PPACA is going to play out for him in the long run. I'd bet on one thing, though. If PPACA is appealed, that rate isn't going to go back down to $300.

WeiWenDi wrote:I personally have not used any more actual coverage while insured than when I was uninsured. People get care when they need it

I couldn't claim the same for myself. I have spent a little over half of my adult life without insurance (either because I couldn't get it even though I was willing to pay for it, or because I was so poor that paying the monthly premiums seemed insane). Through those stages of my life I would only go to the doctor when my condition seemed serious. If I became really sick I would frequently hold off, too, in any hope of forging through it. With healthcare, I'm far more likely to go earlier.

Also worth note is that spending half of my adult life without healthcare has left me with a habit where I calculate my visits far more carefully than I should—where I don't go when, if thinking clearly, I should have gone sooner. I'm working past that now, but something similar might influence the circumstances of others as well. I do agree to some extent, however. Simply gaining the ability to go to the doctor doesn't mean most people are going to start going a whole lot more. It's not like the doctor's office is a favorite destination for many people.

Here's a great example of me not going because I had no insurance: prior to my wedding, I became sick, forged through it, and then became extremely sick. It was only on the morning of my wedding day when it took until 11:00 AM for me to drag my broken down self out of bed that I finally went to the doctor and was diagnosed with, of all things, pneumonia, and not a light case at that. If I had insurance I would have gone to the doctor days ahead.

James wrote:I wonder how many of these people have already been going when bad things are happening with their health and allowing the tax payer to flip the bill. Now, people in that circumstance generally only go when something is really wrong with them, so if they have healthcare they could certainly wind up going more, but is it such a bad thing that they will have healthcare? Healthcare which they are actually paying for in many cases?

it's like i said to WWD before; the only way the demand can go is up. people will not use the system less if they are insured, they will use it more. i wasn't trying to say that this is a bad thing in itself - i think it's good that those cases will be decreased where someone is destroyed financially because they were uninsured and had a necessary but not monumental operation - just that it's true. and it leads to the statement that costs will go up, or quality of services will go down, or both. and given the numbers, i.e. a quick shock of a few tens of millions over just a few years, it won't be an unnoticeable change.

James wrote:As for doctors, if demand for healthcare goes up, demand for doctors go up. I think the economics behind this are a little too hard to predict at this stage because I couldn't say with certainty how all of it is going to play out, but I don't think that will be a problem.

really, they just aren't building new medical schools lately. maybe more doctors will abandon hospitals for private/specialist practices? like i implied above, the new demand will be for routine, non-vital stuff, the kind of thing you make an appointment for. emergency rooms will probably get even more intolerable.

James wrote:

agga wrote:insurance companies are going to have to artificially distort how they distribute premiums ...

I'm not sure we could say anything in confidence here. For example, even if the government has some overhead processing these payments, they are receiving those payments, which offsets costs. As for the private insurance companies, there's a lot of room open for them to approach it from different angles.

i feel like you're being too circumspect here. to offset costs, you need to know what those costs are; but by putting controls on costs - which is what is happening when the govt puts bounds on insurance rates, or requires that coverage be given for cases when the actuaries would decide otherwise - you are distorting prices and hiding the true costs of healthcare services. when you do that, you don't want to underpay for the services, because then the system will fall apart (nurses and doctors and etc will quit), so you play it safe and overpay. another way that total cost will increase.

i think it would be better just to let insurance work the way it does, without any interference, and when there are cases where a person truly cannot afford what he needs, then the government system steps in. if to make this equitable you have to require everyone to have health insurance (including some "we'll cover anybody" public option) or pay a penalty/tax, i have no problem with that.

James wrote:And now on to other aspects of the law. PPACA addresses certain insurance company practices such as dropping someone once they cease to become profitable (I'm not sure people really think about how horrific that practice really is). It also extends healthcare to many people who can't even get healthcare under the current system.

I can actually use myself as an example here. ...

If that's not a representation of some of the things that are so completely messed up with our healthcare system I'm not sure what is, and yet PPACA addresses many of these problems...

i think it's good that more people will have affordable access to the system. i think it's bad that to do this, so many multiple extra layers of government have to be added to what is already a too-complicated, too-restricted, too-regulated system, which causes it to be too expensive for everyone, at every level. i think it would work better, and be less expensive by far if we would simply allow two alternatives: a free (over the whole USA) health insurance market, which would be much more flexible and adaptable than what we have now, and a government insurance system that covers 1) the poor and 2) the otherwise uninsurable.

Today I listened to Steven Brill interviewing for Fresh Air on NPR. I think he did an excellent job of outlining the pros and significant limitations of the Affordable Care Act among related topics, and the discussion got me thinking in a few new directions on something I've been reading about since it was being debated by lawmakers.